The “tax exclusion” for employer‐sponsored health insurance shields workers from paying income or payroll taxes on such benefits. The exclusion is an accident of history that predates modern health insurance and is roughly as old as the income tax itself. It fuels excessive health insurance coverage, medical spending, and health care prices and ties health insurance to employment. It has required Congress to intervene countless times to address problems it creates.
The exclusion requires a worker to let her employer control a sizable share of her earnings, to enroll in a health plan that is likely not her first choice, and to pay the remainder of the premium out of pocket. Overall, the tax code effectively threatens U.S. workers with $352 billion in additional taxes in 2022 if they do not let their employers control $1 trillion of their earnings. The additional tax that workers pay if they do not accept those terms constitutes an implicit penalty.
The tax code thus limits a worker’s ability to make her own health decisions. In the United States, compulsory health spending accounts for 83 percent of overall health spending, the ninth highest share among 34 advanced nations. The tax exclusion is the single largest contributor to compulsory health spending.
Reforming the exclusion would free U.S. workers to control $1 trillion of their earnings that employers currently control, give consumers more health care choices, and make health care more accessible. Building on the bipartisan success of tax‐free health savings accounts appears to present the best politically feasible opportunity for reform. The United States will not have a consumer‐centered health sector until workers control the $1 trillion of their earnings that the exclusion forces them to let employers control.
When is a tax break actually a tax penalty? When it’s the tax exclusion for employer-sponsored health insurance.
That’s what Michael Cannon, Cato Institute’s director of health policy studies, convincingly argues in his recent paper, End the Tax Exclusion for Employer-Sponsored Health Insurance. His paper is a compact lesson in the ways that some supposed tax breaks can effectively function as tax penalties, not only distorting markets, but invisibly penalizing people for their choices. And it’s a reminder of the ways that seemingly minor, offhanded policy decisions, made with little thought to long-term consequences, can exert a haunting influence long after they are made.
The tax exclusion for employer-sponsored health insurance is exactly what it sounds like: a carve-out for health coverage offered through the workplace.
But he argues that, in practical terms, this tax break actually acts as a stealth penalty on workers who want to make their own health insurance choices. Typically even a generous employer only offers a handful of health plans, and those plans are unlikely to take the exact form an employee would otherwise choose on his or her own. If an employee wants to purchase any other plan, however, he or she would have to do it with money first received—and taxed—as cash compensation. Thanks to taxation, it would be worth a lot less. Thus the tax exclusion acts as a tax penalty on any employee who wants to choose their own health insurance.
Given Social Security’s dire financial condition, there is growing interest in attempting to harness the power of private capital markets to bail out the faltering system. However, despite its surface attractiveness, allowing the government to invest funds from the Social Security trust fund in private capital markets would be a terrible mistake that would have severe consequences for the U.S. economy.
Allowing the government to invest the trust fund in private capital markets would amount to the “socialization” of a large portion of the U.S. economy. The federal government would become the nation’s largest shareholder, with a controlling interest in nearly every American company. Government ownership brings with it serious problems of government control and is a threat to the efficiency and competitiveness of the U.S. economy.
Moreover, experience in other countries has shown that government investments seldom achieve the rates of return seen in private investment. Attempts by the government to manipulate the markets could further undermine returns and threaten general market stability.
Spending advocacy groups are still claiming that state and local budget “shortfalls” are hundreds of billions of dollars. It is true that tax revenue growth in 2020 was slower than projected before the pandemic, but that is only a “shortfall” if you assume that budgets must always grow at the strong pre‐pandemic rates. Yet states should know that booms do not last forever. If revenues are growing slower, then states should slow spending growth to match.
Perhaps tax revenues will fall in 2021, as they did in 2009. But that seems unlikely. CBO projected yesterday that real GDP will rise a strong 4.6 percent in calendar 2021. Private forecasters are also projecting solid growth. As incomes rise, state tax revenues should grow. Meanwhile, local governments are gaining from rising house prices because property taxes account for 70 percent of local tax revenues. U.S. house prices in the fourth quarter were up 14.9 percent on the year and are expected to remain strong in 2021.